Failure to Prevent Elopement and Ensure Wheelchair Safety
Penalty
Summary
The facility failed to implement adequate interventions to ensure a safe environment for a resident with cognitive impairment and a history of wandering and behavioral disturbances. The resident, diagnosed with dementia, schizoaffective disorder, and bipolar disorder, was observed attempting to exit the facility and later successfully eloped by opening an exit door and leaving unattended. Prior to the elopement, the resident's care plan did not include specific interventions to prevent exit-seeking behavior, and behavioral monitoring was inconsistently documented, with no records immediately before or after the incident to track the resident's risk of elopement. Additionally, the facility did not ensure the safety of two residents during wheelchair transport. One resident, with an above-the-knee amputation and using a wheelchair for mobility, was observed being pushed by an RN without footrests, resulting in the resident's bare foot brushing against the floor. Another resident, cognitively intact, was also transported in a wheelchair without footrests by a CNA, with her bare toes skimming the floor. These actions were contrary to established wheelchair safety protocols, which require residents' feet to be on footrests during transport to prevent injury.